Your client returns to the gym 12 weeks after an ACL reconstruction surgery, exclaiming, “I’m ready to go!” The client brings motivation and appears to squat, lunge, and even run without concerns. The same client also stopped attending physical therapy because the sessions were “too easy.” Before you embrace your client’s training enthusiasm, here are a few pitfalls and pearls to consider.
Risk Management
Pitfall: While client feelings and motivations are an integral part of holistic training, safety is a significant consideration. Allowing client-directed training can put the client at risk for re-injury. Liability becomes a concern if a client is re-injured under a trainer’s guidance and supervision.
Pearls: While injuries are not always 100% preventable, trainers can follow the STEPS method to help minimize risk:
- Screen: Reviewing the client’s medical history and obtaining the doctor’s permission to return to training opens the conversation to research client-specific precautions.
- Tailor the program design: Personal trainers are key guides in safe and appropriate exercise selection. Matching exercises to healing time guides the client on a successful journey to recovery. Check out the section below to master the art of tailoring.
- Education: Doctors’ visits can be quick without much time for patient conversation. Trainers can add value to sessions and help engage the client’s active participation with a few key education pearls. Check out the graphs below for grab-and-go illustrations to show clients.
- Progression: When progressing clients, consider both time and function. When in doubt, go with whichever is slower.
- Safety first: If in doubt, leave it out. Curiosity is a normal part of wanting to bring more to helping people perform their best. Creativity often shows up in the fitness ecosystem. When applying or creating novel exercises to help clients, first ask what the purpose is, and then ask if it is safe for that particular client at that specific time. Establishing a working relationship with the client’s medical team during the screening sets clients up for an entire collaborative team to support success.
Healing Time
Pitfall: One to six months post-surgery is the most precarious time for ACL healing. Around three – six months post-surgery, clients are often motivated and appear to move normally. They usually don’t understand the risks of the leg extension machine or plyometrics at this point. Too much, too fast, though, presents more risk than benefit.
The graft must progress through three tissue healing phases.
1. In the first three months, the tissues experience necrosis. The graft becomes weaker as the body works to integrate its cells in the repair process.2. The tissue strength improves post-operatively from three to nine months as the body’s blood vessels re-vascularize the area. The new blood vessels bring oxygen and nutrients to facilitate healing.3. This is followed by remodeling nine months to two years post-operatively. At this point, the graft is close to 90% of its strength so that it can withstand forces of more traditional strength and conditioning exercises, unstable surfaces, and multi-planar movements with load and speed.
Pearls: Instead of feeding into the rush to get stronger fast, help support client education by selecting safe exercises. Consider showing them the graph of tissue healing while emphasizing that the actual graft healing is more important than the “ready to go” feeling.
In the first four months post-operatively, avoiding open chain knee extension and multi-directional exercise with speed and load is imperative to preserve healing. Instead, try the following exercises:
1. Non-impact cardiovascular conditioning such as the elliptical or bike. If the rowing machine or swimming pique interest, check with the client’s medical staff first—rowing and swimming present ACL stress at vulnerable angles.2. Closed chain exercises include squats, split squats, RDLs, leg presses, and monster walks with a band above the knees. Be sure to check with the client’s Physical Therapist or surgeon on specific angles. Many only allow the motion to reach 60 degrees of flexion in the first few months.3. Core strength includes hip bridges with the feet on the floor, planks in all directions, and Paloff presses. When progressing to diagonal lifts and chops, cueing for total body pivot so the head, shoulder, hips, knees, and toes always face the same direction helps re-establish core control while minimizing knee torque.4. Controlled balance and proprioception. The repaired area doesn’t come with balance sensors. They need to be retrained. Start with the basics, like a tandem stance on the floor with head turns, unilateral RDLS, and unilateral upper body work while standing on one foot. Before being tempted by the BOSU, be sure the client can perform exercises on a flat surface in various stances. Then, try a foam pad, progressing to a half roller with the flat side down.
Individualization
Pitfall: Starting with the foundations is fabulous. However, As you see more ACL repairs or reconstructions, your curiosity about their medical team’s discrepancies will grow. Overgeneralizing the foundations of every client can lead to missed opportunities or pushing a client too much too fast. All ACL repairs and reconstructions are not the same. The types of grafts heal at different rates. Healing rate differences significantly impact training and athletic choices in the six-month to eighteen-month post-operative period.
Autograft means that the client’s body tissues were used as part of the surgical process. If the autograft comes from the patellar tendon, the healing time is typically nine to eighteen months. In the eighteen to twenty-four-month range, hamstring tendons generally take a bit longer.
Allograft means that cadaver tissues were incorporated into the surgical procedure. Allografts often take twelve to twenty-four months to integrate fully with the client’s tissues.
The medical community also uses synthetic grafts like the LARS procedure. Initial studies indicate a faster return to activity in the six – to twelve-month range since synthetic tissues do not remodel like normal human tissues.
Check out the graph to compare graft types and healing time frames.
Pearls: The most dramatic exercise selection differences based on ACL surgery type start six months post-surgically. While allografts and autografts often start doing more advanced movements, such as lunges and dynamic single-leg work at six months post-operatively, synthetic repairs can usually begin at three months. Additionally, those with allografts and autografts may need to wait until twelve to eighteen months post-surgically to work on traditional agility, plyometrics, and running progressions; those with synthetic repairs can often start such advancements at six months post-surgically.
Overall, the exercise selection foundations do not change. Most clients need to achieve the basic movements of squat, lunge, step up, direction change, static balance, and dynamic balance under progressive speeds and loads to reach their goals. The individualization lies in the timing and exercise scaling to match client abilities and tissue healing time frames.
Next Steps
Leveraging the above ACL pearls and pitfalls, remember risk management, tissue healing, and surgery-specific individualization as your guiding foundations to advance your journey in helping clients with ACL reconstructions and repairs return to fitness. As you incorporate these ideas, wonderful new learning moments and questions will arise. Please share your thoughts on Personal Fitness Professional’s social media to keep the conversation going in real-time collaboration.
Dr. Meredith Butulis, DPT, OCS, CEP, CSCS, CPT, PES, CES, BCS, Pilates-certified, Yoga-certified, has been working in the fitness and rehabilitation fields since 1998. She is the creator of the Fitness Comeback Coaching Certification, author of the Mobility | Stability Equation series, Host of the “Fitness Comeback Coaching Podcast,” and Assistant Professor the State College of Florida. She shares her background to help us reflect on our professional fitness practices from new perspectives that can help us all grow together in the industry. Instagram: @doc.mnb
